Analysis of prognostic factors for postoperative complications and mortality in elderly patients undergoing emergency surgery for intestinal perforation or irreversible intestinal ischemia.

Purpose: Because the global geriatric population continues to increase, the assessment of emergency surgical outcomes in elderly patients with acute peritonitis will become more important. Methods: A retrospective review was conducted on the data of 174 elderly patients who underwent emergency surgery for intestinal perforation or intestinal infarction between June 2010 and November 2022. We conducted an analysis of the risk factors associated with postoperative complications and mortality by evaluating the characteristics of patients and their surgical outcomes. Results: In our study, most patients (94.3%) had preexisting comorbidities, and many patients (84.5%) required transfer to the intensive care unit following emergency surgery. Postoperative complications were observed in 84 individuals (48.3%), with postoperative mortality occurring in 29 (16.7%). Multivariate analysis revealed preoperative acute renal injury, hypoalbuminemia, and postoperative ventilator support as significant predictors of postoperative mortality. Conclusion: When elderly patients undergo emergency surgery for intestinal perforation or infarction, it is important to recognize that those with preoperative acute renal injury, hypoalbuminemia, and a need for postoperative ventilator support have a poor prognosis. Therefore, these patients require intensive care from the early stages of treatment.

Anesthesia for ovarian teratoma resection using remimazolam and remifentanil in a patient with anti-N-methyl-D-aspartate receptor encephalitis -two case reports.

BACKGROUND: Anti-N-methyl-D-aspartate (NMDA) receptor encephalitis is a type of autoimmune encephalitis that causes characteristic symptoms through the formation of antibodies against NMDA receptors. If ovarian teratomas are detected, surgical removal under general anesthesia is often considered. Many general anesthetic agents inhibit NMDA receptors. As such, anesthetic agents may have unexpected effects on disease progression. For anesthesiologists, providing general anesthesia for these patients is challenging and there are few studies on which anesthetic is most appropriate. CASE: Two female patients were diagnosed with anti-NMDA receptor encephalitis and ovarian teratomas. Successful teratoma resection was performed under general anesthesia using remimazolam and remifentanil. After the surgery, one patient showed some improvement but died a month later. The other patient progressively improved over time. CONCLUSIONS: Remimazolam and remifentanil are useful general anesthetic agents for patients with anti-NMDA receptor encephalitis. Further studies are warranted.

Perforation on the superior side of duodenum is a risk factor of laparoscopic primary repair for duodenal ulcer perforation.

PURPOSE: Primary repair is the standard surgical method for treating duodenal ulcer perforations, with very good results usually anticipated because of the simplicity of the associated surgical techniques. Therefore, this study aimed to analyze the risk factors that affect laparoscopic primary repair outcomes for duodenal ulcer perforation. METHODS: Between June 2010 and June 2020, 124 patients who underwent laparoscopic primary repair for duodenal ulcer perforations were reviewed. Early surgical outcomes were evaluated and risk factors for postoperative complications were assessed. RESULTS: All surgeries were performed laparoscopically without open conversion. Multivariate analysis showed that the elderly (over 70 years), and perforations that needed more than 2 stitches for closure were risk factors for overall postoperative complications. Perforations that needed more than 2 stitches and perforations on the superior side of the duodenum were major risk factors for severe postoperative complications. Severe postoperative complications occurred in 6 of the patients, and 1 of them died of multiorgan failure. CONCLUSION: Based on our results, we suggest that laparoscopic primary repair can be safely performed in duodenal ulcer perforation. However, more careful surgery and postoperative care are needed to improve the surgical outcomes of patients who need more than 2 stitches to close their perforation or who have perforations on the superior side of the duodenum.

Surgical Outcomes and Survival Prognostic Factors for Palliative Gastrectomies in Stage IV Resectable Gastric Cancer Outlet Obstruction Patients.

PURPOSE: Currently, there is no clear evidence to support any specific treatment as a principal therapy for stage IV gastric cancer outlet obstruction (GCOO) patients. This study evaluated the outcomes of palliative gastrectomies and survival prognostic factors in patients with stage IV resectable GCOO. MATERIALS AND METHODS: We retrospectively reviewed the medical records of 48 stage IV GCOO patients who underwent palliative gastrectomies between June 2010 and December 2019. Palliative gastrectomies were performed only in patients with resectable disease. Early surgical outcomes and prognostic factors were analyzed using univariate and multivariate analyses. RESULTS: There were no specific risk factors for postoperative complications, except for being underweight. Severe postoperative complications developed in five patients, and most of the patients underwent interventional procedures and received broad-spectrum antibiotics for intra-abdominal abscesses. The multivariate survival analysis showed that palliative chemotherapy is a positive prognostic factor, while the specific type of hematogenous and lymphatic metastasis is a negative prognostic factor. CONCLUSIONS: We recommend that the treatment method for stage IV GCOO should be selected according to each patient's physical condition and tumor characteristics. In addition, we suggest that palliative gastrectomies can be performed in stage IV resectable GCOO patients without unfavorable prognostic factors (types of hematogenous and lymphatic metastases).

Ultrasound-guided greater occipital nerve block with botulinum toxin for patients with chronic headache in the occipital area: a randomized controlled trial.

BACKGROUND: Ultrasound-guided greater occipital nerve (GON) block has been frequently used to treat various types of headaches, and botulinum toxin has recently begun to be used in patients with headache. Our study presents the long-term effect of botulinum toxin on GON block using ultrasound in patients with chronic headache in occipital area. METHODS: Patients with occipital headache were divided into two groups (bupivacaine: BUP group [n = 27], botulinum toxin: BTX group [n = 27]), and ultrasound-guided GON block was performed at the C2 level. GON was detected with ultrasound and distance from GON to midline, from the skin surface to GON, and size of GON were measured in both groups. Visual analogue scale (VAS) scores and Likert scale were assessed at pretreatment and at 1, 4, 8, and 24 weeks after treatment in both groups. RESULTS: The distance from GON to midline was 18.9 ± 4.4 mm (right) and 17.3 ± 3.8 mm (left). The depth from the skin was 12.9 ± 1.5 mm (right) and 13.4 ± 1.6 mm (left). GON size was 3.1 mm on both sides. The VAS score and patient satisfaction score (Likert scale) in 4, 8, and 24 weeks after injection were superior for the BTX than the BUP group. CONCLUSIONS: Ultrasound-guided GON block using BTX is effective in reducing short-term and long-term pain in patients with chronic headache in the occipital area.

Extending the Indication for Laparoscopic Surgery in Patients With Pan-Peritonitis.

BACKGROUND: There have been reports of favorable results in patients with peritonitis who underwent laparoscopic surgery. The present study evaluated the outcomes of laparoscopic surgery in patients with pan-peritonitis. MATERIALS AND METHODS: We enrolled 148 patients who underwent open and laparoscopic surgery for pan-peritonitis between January 2015 and December 2017 at Hanyang University Guri Hospital. Patients with appendicitis or cholecystitis were excluded from this study because of the simplicity of the technique and the favorable postoperative prognosis. Surgical outcomes including open conversion, morbidity, mortality, risk, and prognostic factors were evaluated. RESULTS: During the study period, 125 patients (84.5%) underwent laparoscopic surgery. The conversion to open surgery occurred in 7 (5.3%) patients. In the laparoscopic surgery group, 27 patients (21.6%) experienced postoperative complications, and 6 died (4.8%). Multivariate analysis showed that age of older than 75 years was a risk factor for postoperative complications. Especially, preoperative shock (<90 mm Hg) and a longer time from symptom onset (over 2 d) to surgery were prognostic factors for postoperative mortality. CONCLUSIONS: On the basis of our results and experiences, we believe that laparoscopic surgery is applicable to surgery of pan-peritonitis. And, preoperative shock and longer time from onset are prognostic factors of mortality in laparoscopic group. Therefore, we are confident that careful patient selection and specialized laparoscopic team should be considered in order to have best results.

The functional role of protease-activated receptors on contractile responses by activation of Ca2+ sensitization pathways in simian colonic muscles.

It has been known that activation of protease-activated receptors (PARs) affects gastrointestinal motility. In this study, we tested the effects of PAR agonists on electrical and contractile responses and Ca2+ sensitization pathways in simian colonic muscles. The Simian colonic muscle was initially hyperpolarized by PAR agonists. After the transient hyperpolarization, simian colonic muscle repolarized to the control resting membrane potential (RMP) without a delayed depolarization. Apamin significantly reduced the initial hyperpolarization, suggesting that activation of small conductance Ca2+-activated K+ (SK) channels is involved in the initial hyperpolarization. In contractile experiments, PAR agonists caused an initial relaxation followed by an increase in contractions. These delayed contractile responses were not matched with the electrical responses that showed no after depolarization of the RMP. To investigate the possible involvement of Rho-associated protein kinase 2 (ROCK) pathways in the PAR effects, muscle strips were treated with ROCK inhibitors, which significantly reduced the PAR agonist-induced contractions. Furthermore, PAR agonists increased MYPT1 phosphorylation, and ROCK inhibitors completely blocked MYPT1 phosphorylation. PAR agonists alone had no effect on CPI-17 phosphorylation. In the presence of apamin, PAR agonists significantly increased CPI-17 phosphorylation, which was blocked by protein kinase C (PKC) inhibitors suggesting that Ca2+ influx is increased by apamin and is activating PKC. In conclusion, these studies show that PAR activators induce biphasic responses in simian colonic muscles. The initial inhibitory responses by PAR agonists are mainly mediated by activation of SK channels and delayed contractile responses are mainly mediated by the CPI-17 and ROCK Ca2+ sensitization pathways in simian colonic muscles. NEW & NOTEWORTHY In the present study, we found that the contractile responses of simian colonic muscles to protease-activated receptor (PAR) agonists are different from the previously reported contractile responses of murine colonic muscles. Ca2+ sensitization pathways mediate the contractile responses of simian colonic muscles to PAR agonists without affecting the membrane potential. These findings emphasize novel mechanisms of PAR agonist-induced contractions possibly related to colonic dysmotility in inflammatory bowel disease.

End-tidal concentration of sevoflurane for reducing rocuronium-induced withdrawal reactions in adult patients: a comparison between male and female patients.

BACKGROUND: In this study, we assessed the 50% effective concentration (EC50) of sevoflurane for reducing a rocuronium-induced reaction, based on the Dixon's up-and-down method. We also assessed the 50 and 95% effective end-tidal concentration of sevoflurane (ETsev), based on the probit regression curve of the probability of nonwithdrawal reaction. METHODS: We conducted a prospective, double-blind study in 23 males and 24 females. After using 2.5% thiopental sodium (4 mg/kg), anesthesia was induced in the patients. The patients then inhaled sevoflurane with 5 vol% in 6 L/min of oxygen. When the target ETsev was achieved, a nurse injected the intubating dose of rocuronium (0.6 mg/kg) for 5-10 s under the free flow of intravenous fluid. After the nurse evaluated the response, the nurse recorded the maximum heart rate during 30 s and the mean arterial pressure after rocuronium injection. RESULTS: Based on Dixon's up-and-down method, the EC50 of sevoflurane was 2.5 ± 0.5 vol% in males and 2.5 ± 0.3 vol% in females. The probit regression curve of the probability of nonwithdrawal reaction showed that in males the 50% effective ETsev was 2.4 vol% (95% confidence interval [CI], 1.5-3.1 vol%) and the 95% effective ETsev was 3.5 vol% (95% CI, 2.9-11.0 vol%); in females, the 50% effective ETsev was 2.4 vol% (95% CI, 2.1-2.7 vol%) and the 95% effective ETsev was 3.0 vol% (95% CI, 2.7-4.5 vol%). CONCLUSIONS: The inhalation of sevoflurane during the induction period may provide a simple and reliable means of reducing rocuronium-induced reactions without adverse hemodynamic changes. There was no significant difference between males and females.

End-tidal concentration of sevoflurane for preventing rocuronium-induced withdrawal of the arm in pediatric patients.

BACKGROUND: During induction of general anesthesia, the intravenous injection of rocuronium is often associated with withdrawal movement of the arm due to pain, and this abrupt withdrawal may result in dislodgement of the venous catheter, injury, or inadequate injection of rocuronium. We performed this study to evaluate the 50 and 95% effective end-tidal concentrations of sevoflurane (ETsev) for preventing rocuronium-induced withdrawal of the arm. METHODS: We conducted a prospective double-blind study in 31 pediatric patients. After free flow of lactated Ringer's IV fluid was confirmed, anesthesia was induced in the patients by using 2.5% thiopental sodium (4 mg/kg) and sevoflurane (4 vol%) with 6 L/min of oxygen. When the target ETsev was reached, preservative-free 1% lidocaine (1.5 mg/kg) was intravenously injected during manual venous occlusion and rocuronium (0.6 mg/kg) was injected after lidocaine injection under free-flow intravenous fluid. A nurse who was an investigator and was blinded to the ETsev injected the rocuronium. The nurse evaluated the response. RESULTS: Non-withdrawal movement was observed in 5 out of 11 patients with ETsev 3.0 vol% and in 5 out of 6 patients with ETsev 3.5 vol%. By Dixon's up-and-down method, the 50% effective concentration (EC50) of sevoflurane for non-withdrawal movement at rocuronium injection was 3.1 ± 0.4 vol%. A logistic regression curve of the probability of non-withdrawal movements showed that the 50% effective ETsev for abolishing withdrawal movement at rocuronium injection was 2.9 vol% (95% confidence interval [CI] 2.4-3.8 vol%) and the 95% effective ETsev was 4.3 vol% (95% CI 3.6-9.8 vol%). CONCLUSIONS: This study showed that the 50 and 95% effective ETsev that prevent withdrawal movement at rocuronium injection are 2.9 and 4.3 vol%, respectively.